Dr. Adam Witkowski,
Drug-eluting stents (DES) nowadays are used in about 30% - 100% of patients undergoing PCI in Europe. There are still unresolved issues on current indications, optimization of implantation techniques and adjunctive antiplatelet therapy for DES. Also there is not much evidence about the efficacy and safety of next generation DES. Today’s session intended to clarify these issues.
Dr Sigmund Silber from Munich reviewed current indications for DES. He informed us that despite the fact that 22 different DES already received the CE mark, only a few of them have high-level clinical evidence from randomized trials. There is also no class effect within different DES. In his opinion, the question should not be about who should receive DES, but rather, who should not. For example, patients who cannot take prolonged dual antiplatalet therapy (DAT) because they are awaiting major surgery should received bare-metal stents and patients with SYNATX Score over 33 should be referred for CABG surgery.
The second presentation was given by Dr Carlo DiMario from London. He focused on optimization od DES implantation. He emphasized the choice of the right lesion for stenting based on the results of the functional invasive or non-invasive studies like MRI, SPECT and FFR. Secondly, he showed that optimization of DES implantation with non-compliant balloons under IVUS or OCT guidance with final in-stent area of more then 5.0-5.8 mm2 will produce better clinical outcome. Finally, he stressed that side-branches should be protected (and dilated if neccesary), especially with a long DES implanted in a main vessel.
The third speaker, Dr Germano Di Sciascio from Rome, clarified the use of adjunctive DAT with DES. According to the ESC PCI Guidelines published in 2005, a 300 mg loading dose of clopidogrel is generally accepted for elective cases, but 600 mg should be given in more urgent situations. A maintenance dose of 75 mg is recommended for up to 12 months after DES implantation. Based on evidence from the randomized Armyda-Reload Trial reloading with clopidogrel in patients who are already taking this medication but required PCI should be considered within the settings of acute coronary syndromes but not in patients with stable angina. In patients with high residual platelet reactivity after standard clopidogrel regimen, the double maintenance dose of 150 mg daily may be beneficial.
Finally, Dr Bernard Chevalier from Massy dealt with the interesting topic of new generation DES. We need new DES he said, because we were looking for stents with better deliverability, efficacy and safety. These goals could be achieved with the reduction of metallic stent struts and polymer, with biodegradable polymers and fully biodegradable stents and with multi-drug eluting stents. However, up to date new stents released already to clinical use did not broaden the current indication for DES. In his opinion DAT after DES should not be prescribed for more than 6 months, beacuse there is no evidence from trials and registries that longer DAT translates into more safety.
What every cardiologist should know about drug-eluting stents
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